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Eggers KM, Batra G, Lindahl B, Ghukasyan Lakic T, Lindbäck J, Budaj A, Cornel JH, Giannitsis E, Katus HA, Storey RF, Becker RC, Siegbahn A, Wallentin L. Temporal biomarker concentration patterns during the early course of acute coronary syndrome. Clin Chem Lab Med 2024; 62:1167-1176. [PMID: 38341860 DOI: 10.1515/cclm-2023-1253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVES Biomarker concentrations and their changes during acute coronary syndrome (ACS) provide clinically useful information on pathophysiological processes, e.g. myocardial necrosis, hemodynamic stress and inflammation. However, current evidence on temporal biomarker patterns early during ACS is limited, and studies investigating multiple biomarkers are lacking. METHODS We measured concentrations of high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI), NT-terminal pro-B-type natriuretic peptide, C-reactive protein, and growth-differentiation factor-15 (GDF-15) in plasma samples obtained at randomization in ACS patients from the PLATelet inhibition and patient Outcomes (PLATO) trial. Linear regressions with interaction analyses were used to investigate the associations of biomarker concentrations with the time from symptom onset and to model temporal biomarker concentration patterns. RESULTS The study population consisted of 16,944 patients (median age 62 years; 71.3 % males) with 6,853 (40.3 %) having ST-elevation myocardial infarction (STEMI) and 10,141 (59.7 %) having non-ST-elevation ACS (NSTE-ACS). Concentrations of all biomarkers were associated with time from symptom onset (pinteraction<0.001), apart for GDF-15 (pinteraction=0.092). Concentration increases were more pronounced in STEMI compared to NSTE-ACS. Temporal biomarker patterns for hs-cTnT and hs-cTnI were different depending on sex whereas biomarker patterns for the other biomarkers were similar in cohorts defined by age and sex. CONCLUSIONS Temporal concentration patterns differ for various biomarkers early during ACS, reflecting the variability in the activation and duration of different pathophysiological processes, and the amount of injured myocardium. Our data emphasize that the time elapsed from symptom onset should be considered for the interpretation of biomarker results in ACS.
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Affiliation(s)
- Kai M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Gorav Batra
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Andrzej Budaj
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Jan H Cornel
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
- Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Hugo A Katus
- Department of Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Robert F Storey
- Division of Clinical Medicine, University of Sheffield and NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Richard C Becker
- Division of Cardiovascular Health and Diseases, University of Cincinnati, Heart, Lung & Vascular Institute, Cincinnati, USA
| | - Agneta Siegbahn
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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2
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Bhatia HS, Becker RC, Leibundgut G, Patel M, Lacaze P, Tonkin A, Narula J, Tsimikas S. Lipoprotein(a), platelet function and cardiovascular disease. Nat Rev Cardiol 2024; 21:299-311. [PMID: 37938756 DOI: 10.1038/s41569-023-00947-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/09/2023]
Abstract
Lipoprotein(a) (Lp(a)) is associated with atherothrombosis through several mechanisms, including putative antifibrinolytic properties. However, genetic association studies have not demonstrated an association between high plasma levels of Lp(a) and the risk of venous thromboembolism, and studies in patients with highly elevated Lp(a) levels have shown that Lp(a) lowering does not modify the clotting properties of plasma ex vivo. Lp(a) can interact with several platelet receptors, providing biological plausibility for a pro-aggregatory effect. Observational clinical studies suggest that elevated plasma Lp(a) concentrations are associated with worse long-term outcomes in patients undergoing revascularization. Furthermore, in these patients, those with elevated plasma Lp(a) levels derive more benefit from prolonged dual antiplatelet therapy than those with normal Lp(a) levels. The ASPREE trial in healthy older individuals treated with aspirin showed a reduction in ischaemic events in those who had a single-nucleotide polymorphism in LPA that is associated with elevated Lp(a) levels in plasma, without an increase in bleeding events. In this Review, we re-examine the role of Lp(a) in the regulation of platelet function and suggest areas of research to define further the clinical relevance to cardiovascular disease of the observed associations between Lp(a) and platelet function.
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Affiliation(s)
- Harpreet S Bhatia
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA, USA
| | - Richard C Becker
- Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregor Leibundgut
- Division of Cardiology, University Hospital of Basel, Basel, Switzerland
| | - Mitul Patel
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA, USA
| | - Paul Lacaze
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Tonkin
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sotirios Tsimikas
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA, USA.
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3
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Eckman MH, Wise R, Knochelmann C, Mardis R, Leonard AC, Wright S, Gummadi A, Dixon E, Becker RC, Schauer DP, Flaherty ML, Costea A, Kleindorfer D, Ireton R, Baker P, Harnett BM, Adejare A, Sucharew H, Arduser L, Kues J. Can a best practice advisory improve anticoagulation prescribing to reduce stroke risk in patients with atrial fibrillation? J Cardiol 2024; 83:285-290. [PMID: 37579873 DOI: 10.1016/j.jjcc.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common cardiac rhythm disorder and a risk factor for stroke. Randomized trials have demonstrated that anticoagulation can reduce strokes in AF patients. Yet, widespread underutilization of this therapy continues. To address this practice gap, we designed a study to implement and evaluate the effectiveness of a best practice advisory (BPA) for an Atrial Fibrillation Decision Support Tool (AFDST) embedded within our electronic health record. METHODS Our intervention is provider-facing, focused on decision support. Clinical setting is ambulatory patients being seen by primary care physicians. We prospectively enrolled 608 patients in our health system who are currently receiving less than optimal anticoagulation therapy as determined by the AFDST and randomized them to one of two arms - 1) usual care, in which the AFDST is available for use; or 2) addition of a BPA to the AFDST notifying clinicians that their patient stands to gain significant benefit from a change in current therapy. Primary outcome was effectiveness of the BPA measured by change to "appropriate thromboprophylaxis" based on the AFDST recommendation at 3 months post-enrollment. Secondary endpoints included Reach and Adoption from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, & Maintenance) framework for implementation studies. RESULTS Among 562 patients with a minimum follow-up of 3 months, addition of a BPA to the AFDST resulted in significant improvement in anticoagulation therapy, 5 % (12/248) versus 11 % (33/314) p = 0.02, odds ratio 2.31 (95 % CI, 1.17-4.87). CONCLUSIONS A BPA added to an AF decision support tool improved anticoagulation therapy among AF patients in a primary care academic health system setting.
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Affiliation(s)
- Mark H Eckman
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Ruth Wise
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carol Knochelmann
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rachael Mardis
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Anthony C Leonard
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sharon Wright
- Department of Pharmacy, University Hospital, Cincinnati, OH, USA
| | - Ashish Gummadi
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Estrelita Dixon
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel P Schauer
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Matthew L Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Dawn Kleindorfer
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Rob Ireton
- Center for Health Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Pete Baker
- Center for Health Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brett M Harnett
- Center for Health Informatics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Heidi Sucharew
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lora Arduser
- Department of English, University of Cincinnati, Cincinnati, OH, USA
| | - John Kues
- Department of Family and Community Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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4
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Ali AE, Becker RC. The foundation for investigating factor XI as a target for inhibition in human cardiovascular disease. J Thromb Thrombolysis 2024:10.1007/s11239-024-02985-0. [PMID: 38662114 DOI: 10.1007/s11239-024-02985-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 04/26/2024]
Abstract
Anticoagulant therapy is a mainstay in the management of patients with cardiovascular disease and related conditions characterized by a heightened risk for thrombosis. Acute coronary syndrome, chronic coronary syndrome, ischemic stroke, and atrial fibrillation are the most common. In addition to their proclivity for thrombosis, each of these four conditions is also characterized by local and systemic inflammation, endothelial/endocardial injury and dysfunction, oxidative stress, impaired tissue-level reparative capabilities, and immune dysregulation that plays a critical role in linking molecular events, environmental triggers, and phenotypic expressions. Knowing that cardiovascular disease and thrombosis are complex and dynamic, can the scientific community identify a common pathway or specific point of interface susceptible to pharmacological inhibition or alteration that is likely to be safe and effective? The contact factors of coagulation may represent the proverbial "sweet spot" and are worthy of investigation. The following review provides a summary of the fundamental biochemistry of factor XI, its biological activity in thrombosis, inflammation, and angiogenesis, new targeting drugs, and a pragmatic approach to managing hemostatic requirements in clinical trials and possibly day-to-day patient care in the future.
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Affiliation(s)
- Ahmed E Ali
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Richard C Becker
- Department of Internal Medicine, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
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5
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Ali AE, Becker RC. Factor XI: structure, function and therapeutic inhibition. J Thromb Thrombolysis 2024:10.1007/s11239-024-02972-5. [PMID: 38622277 DOI: 10.1007/s11239-024-02972-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/17/2024]
Abstract
Arterial and venous thromboembolism is a major medical concern that requires therapeutic anticoagulation in various medical fields to prevent its drastic consequences. Despite significant advances in anticoagulant therapy, thrombosis remains a leading cause of morbidity and mortality worldwide. Traditional anticoagulants like heparin and vitamin K antagonists (VKAs) have shown efficacy in preventing and treating thrombosis but come with an inherent risk of bleeding due to their non-specific inhibition of multiple coagulation factors. Subsequent direct oral anticoagulants (DOACs), targeting specific factors such as Xa or thrombin, demonstrated improved safety profiles compared to VKAs, yet bleeding remains a concern. Accordingly, research is focused on developing anticoagulants with improved safety profiles. A safer class of anticoagulants would have broad appeal. The intrinsic pathway of coagulation, involving factor XI (FXI), has attracted attention as a potential target for safer anticoagulants. Preclinical studies and epidemiological data indicate that FXI deficiency or inhibition protects against thrombosis with minimal bleeding. Current research involves evaluating various FXI-directed strategies, and phase 2 studies have shown promising results in orthopedic surgery, atrial fibrillation, end-stage renal disease (ESRD), myocardial infarction, and ischemic stroke. Several agents, such as antisense oligonucleotides, monoclonal antibodies, small synthetic molecules, natural peptides, and aptamers, have been developed to inhibit FXI at different stages, offering potentially safer alternatives to traditional anticoagulants. However, the optimal balance between preventing thrombosis and the risk of bleeding associated with FXI inhibitors requires validation through extensive phase 3 clinical trials using definite clinical endpoints. Several of such trials are currently underway or planned to define the role of FXI inhibitors in clinical practice and determine the most suitable FXI inhibitor for each specific indication. The current review highlights the rationale behind developing FXI inhibitors, presenting the most advanced agents in development, summarizing completed clinical trials, and discussing ongoing research efforts.
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Affiliation(s)
- Ahmed E Ali
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Richard C Becker
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA.
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6
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Davidsson P, Eketjäll S, Eriksson N, Walentinsson A, Becker RC, Cavallin A, Bogstedt A, Collén A, Held C, James S, Siegbahn A, Stewart R, Storey RF, White H, Wallentin L. Vascular endothelial growth factor-D plasma levels and VEGFD genetic variants are independently associated with outcomes in patients with cardiovascular disease. Cardiovasc Res 2023; 119:1596-1605. [PMID: 36869765 DOI: 10.1093/cvr/cvad039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 12/21/2022] [Accepted: 01/05/2023] [Indexed: 03/05/2023] Open
Abstract
AIMS The vascular endothelial growth factor (VEGF) family is involved in pathophysiological mechanisms underlying cardiovascular (CV) diseases. The aim of this study was to investigate the associations between circulating VEGF ligands and/or soluble receptors and CV outcome in patients with acute coronary syndrome (ACS) and chronic coronary syndrome (CCS). METHODS AND RESULTS Levels of VEGF biomarkers, including bFGF, Flt-1, KDR (VEGFR2), PlGF, Tie-2, VEGF-A, VEGF-C, and VEGF-D, were measured in the PLATO ACS cohort (n = 2091, discovery cohort). Subsequently, VEGF-D was also measured in the STABILITY CCS cohort (n = 4015, confirmation cohort) to verify associations with CV outcomes. Associations between plasma VEGF-D and outcomes were analysed by multiple Cox regression models with hazard ratios (HR [95% CI]) comparing the upper vs. the lower quartile of VEGF-D. Genome-wide association study (GWAS) of VEGF-D in PLATO identified SNPs that were used as genetic instruments in Mendelian randomization (MR) meta-analyses vs. clinical endpoints. GWAS and MR were performed in patients with ACS from PLATO (n = 10 013) and FRISC-II (n = 2952), and with CCS from the STABILITY trial (n = 10 786). VEGF-D, KDR, Flt-1, and PlGF showed significant association with CV outcomes. VEGF-D was most strongly associated with CV death (P = 3.73e-05, HR 1.892 [1.419, 2.522]). Genome-wide significant associations with VEGF-D levels were identified at the VEGFD locus on chromosome Xp22. MR analyses of the combined top ranked SNPs (GWAS P-values; rs192812042, P = 5.82e-20; rs234500, P = 1.97e-14) demonstrated a significant effect on CV mortality [P = 0.0257, HR 1.81 (1.07, 3.04) per increase of one unit in log VEGF-D]. CONCLUSION This is the first large-scale cohort study to demonstrate that both VEGF-D plasma levels and VEGFD genetic variants are independently associated with CV outcomes in patients with ACS and CCS. Measurements of VEGF-D levels and/or VEGFD genetic variants may provide incremental prognostic information in patients with ACS and CCS.
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Affiliation(s)
- Pia Davidsson
- Translational Science and Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Pepparedsleden 1, 431 83 Mölndal, Sweden
| | - Susanna Eketjäll
- Translational Science and Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Pepparedsleden 1, 431 83 Mölndal, Sweden
| | - Niclas Eriksson
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
| | - Anna Walentinsson
- Translational Science and Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Pepparedsleden 1, 431 83 Mölndal, Sweden
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0542, Cincinnati, OH, 45267, USA
| | - Anders Cavallin
- Translational Science and Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Pepparedsleden 1, 431 83 Mölndal, Sweden
| | - Anna Bogstedt
- Translational Science and Experimental Medicine, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Pepparedsleden 1, 431 83 Mölndal, Sweden
| | - Anna Collén
- Projects, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Pepparedsleden 1, 431 83 Mölndal, Sweden
| | - Claes Held
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Akademiska Sjukhuset, 751 85 Uppsala, Sweden
| | - Stefan James
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Akademiska Sjukhuset, 751 85 Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Akademiska Sjukhuset, 751 85 Uppsala, Sweden
- Clinical Chemistry, Uppsala University, Akademiska Sjukhuset, 751 85 Uppsala, Sweden
| | - Ralph Stewart
- Green Lane Cardiovascular Service, Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Harvey White
- Green Lane Cardiovascular Service, Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Akademiska Sjukhuset, 751 85 Uppsala, Sweden
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7
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Wang TY, Svensson LG, Wen J, Vekstein A, Gerdisch M, Rao VU, Moront M, Johnston D, Lopes RD, Chavez A, Ruel M, Blackstone EH, Becker RC, Thourani V, Puskas J, Al-Khalidi HR, Cable DG, Elefteriades JA, Pochettino A, Wolfe JA, Graeve A, Sultan I, Sabe AA, Michelena HI, Alexander JH. Apixaban or Warfarin in Patients with an On-X Mechanical Aortic Valve. NEJM Evid 2023; 2:EVIDoa2300067. [PMID: 38320162 DOI: 10.1056/evidoa2300067] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Apixaban, Warfarin, and On-X Mechanical Aortic ValvesAlthough vitamin K antagonists are the only oral anticoagulants approved with mechanical heart valves, this trial examined whether apixaban could be safely used in patients with an On-X mechanical aortic valve. A total of 863 such patients were assigned apixaban 5 mg twice daily or warfarin (target international normalized ratio 2.0 to 3.0). A total of 20 thrombotic events occurred in the apixaban group (4.2%/patient-year) and 6 events in the warfarin group (1.3%/patient-year). Major bleeding rates were 3.6%/patient-year with apixaban and 4.5%/patient-year with warfarin.
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Affiliation(s)
- Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Jun Wen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Andrew Vekstein
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Alma Chavez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, ON
| | | | | | | | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - David G Cable
- OSF HealthCare Cardiovascular Institute, Rockford, IL
| | | | | | - J Alan Wolfe
- Northeast Georgia Medical Center, Gainesville, GA
| | - Allen Graeve
- MultiCare Institute for Research and Innovation, Tacoma, WA
| | | | - Ashraf A Sabe
- Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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8
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Khan MH, Becker RC. Cardiopulmonary Phenotypes of Post Acute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2: A Narrative Review. Cardiol Rev 2023; 31:117-127. [PMID: 37036191 DOI: 10.1097/crd.0000000000000429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The acute effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are well known; however, the long-term cardiopulmonary effects are less well characterized. The phenotypic expression of acute infection is heterogeneous, ranging from a complete absence of symptoms to shock, multisystem organ failure, and death. Patients with severe or critical coronavirus disease (COVID-19) who survive their initial illness can require a prolonged period of recovery lasting weeks to months. This specific patient group is part of a larger and even more heterogeneous group of patients who initially experience mild-to-moderate symptoms that fail to resolve over time. Collectively, patients recovering from severe or critical COVID-19 and those who continue to experience symptoms following a lower acuity infection are considered to have Post Acute Sequalae of SARS-CoV-2 infection (PASC). Using prognostic factors like myocardial infarction, myocarditis, pulmonary embolism, acute respiratory distress syndrome, need for mechanical ventilation or extracorporeal membrane oxygenation, and advanced pharmaceutical therapies that primarily occur or are instituted in the acute phase of illness one can begin to develop a taxonomy or corpus of PASC in its varied forms.
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Affiliation(s)
- Muhammad H Khan
- From the Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Richard C Becker
- University of Cincinnati Heart, Lung and Vascular Institute, Cincinnati, OH
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Becker RC. Evaluating chest pain in patients with post COVID conditions permission to think outside of the box. J Thromb Thrombolysis 2023; 55:592-603. [PMID: 37052772 PMCID: PMC10098243 DOI: 10.1007/s11239-023-02808-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2023] [Indexed: 04/14/2023]
Abstract
Chest pain is among the most common symptoms of post-COVID-19 Conditions (PCC) that prompts medical attention. Because the SARS-CoV-2 virus has proclivity for many organs and organ systems in the chest, ranging from the heart, lungs, great vessels, lymphatics, and peripheral nerves, clinicians evaluating patients with chest pain must consider a broad differential diagnosis and take a comprehensive approach to management.
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10
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Becker RC, Ortel TL. Anticoagulation in Patients With COVID-19 Pneumonia-What Is the Optimal Intensity? JAMA Intern Med 2023:2802822. [PMID: 36946227 DOI: 10.1001/jamainternmed.2023.0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Affiliation(s)
- Richard C Becker
- University of Cincinnati Heart, Lung, and Vascular Institute, Cincinnati, Ohio
| | - Thomas L Ortel
- Departments of Medicine and Pathology, Division of Hematology, Duke University Medical Center, Durham, North Carolina
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Walker J, Alhasan F, Hendrix A, Becker RC. MANAGEMENT OF HIGH OUTPUT HEART FAILURE IN HEREDITARY HEMORRHAGIC TELANGIECTASIA. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)03090-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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12
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Nimjee SM, Wheeler D, Nelson S, Shea RJ, Sullivan T, Mayer C, Pavliv L, Layzer JM, Lickliter J, Sullenger B, Campbell B, Becker RC. Abstract 94: Randomized, Double-blind, Placebo-controlled Phase 1 Study Of Vwf-binding Aptamer, Bb-031: Safety, Tolerability, Pharmacokinetic And Pharmacodynamic Activity In Healthy Volunteers. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Von Willebrand Factor (VWF) is a ubiquitous component of thrombi extracted by endovascular thrombectomy from patients with large vessel occlusion (LVO) stroke. BB-031 is a modified RNA aptamer that targets von Willebrand Factor (VWF) that lyses occlusive thrombi and improves outcomes in pre-clinical models of acute ischemic stroke (AIS).
Hypothesis:
BB-031 is safe, tolerable, and inhibits both VWF binding and activity in a dose-dependent manner.
Methods:
Healthy participants were randomized to receive BB-031 or placebo (6:2) by intravenous bolus injection at single ascending doses (SAD) of 0.1, 0.3, 1.0, 2.0 and 4.0 mg/kg (total n=40). Serial Clinical assessment, and blood sample collection for pharmacokinetic (PK) and pharmacodynamic (PD) analysis were performed. Non-compartmental PK analysis was conducted using Phoenix WinNonlin. PD evaluation included measurement of VWF inhibition and whole blood thrombosis (Platelet Function Analyzer [PFA-200]).
Results:
BB-031 was safe and well-tolerated for 28 days following single IV doses up to 4.0 mg/kg. There were no significant adverse events (SAEs), or treatment-emergent adverse events (TEAEs) leading to dose discontinuation. Minor events included bleeding at an IV site in 1 participant, and minor bleeding of an ulcer on the tongue in 1 participant. None of the minor TEAEs were dose-dependent. BB-031 demonstrated nonlinear, dose-dependent plasma PK across the dose range tested, with an apparent mean terminal half-life (t
1/2
) of 18 min at 0.1 mg/kg to 67 min at 4.0 mg/kg. Dose-dependent changes in VWF binding were observed; >95% maximal mean change from baseline was reached following a single IV dose of 4.0 mg/kg. Finally, PFA-200 results showed complete inhibition of clot formation (closing time ≥300 seconds) at all doses tested with a dose-dependent duration of inhibition and return to normal range.
Conclusion:
This first-in-human SAD study of BB-031 demonstrated safety following a single IV dose of 0.1 to 4 mg/kg, and dose-dependent patterns of VWF binding and platelet function changes. These results lay the foundation for future studies in patients suffering from thrombotic conditions including AIS.
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Affiliation(s)
| | | | | | | | | | | | - Leo Pavliv
- Cumberland Pharmaceuticals, Morrisville, NC
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13
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Ren L, Du W, Song D, Lu H, Hamblin MH, Wang C, Du C, Fan GC, Becker RC, Fan Y. Genetic ablation of diabetes-associated gene Ccdc92 reduces obesity and insulin resistance in mice. iScience 2023; 26:105769. [PMID: 36594018 PMCID: PMC9804112 DOI: 10.1016/j.isci.2022.105769] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/30/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Multiple genome-wide association studies (GWAS) have identified specific genetic variants in the coiled-coil domain containing 92 (CCDC92) locus that is associated with obesity and type 2 diabetes in humans. However, the biological function of CCDC92 in obesity and insulin resistance remains to be explored. Utilizing wild-type (WT) and Ccdc92 whole-body knockout (KO) mice, we found that Ccdc92 KO reduced obesity and increased insulin sensitivity under high-fat diet (HFD) conditions. Ccdc92 KO inhibited macrophage infiltration and fibrosis in white adipose tissue (WAT), suggesting Ccdc92 ablation protects against adipose tissue dysfunction. Ccdc92 deletion also increased energy expenditure and further attenuated hepatic steatosis in mice on an HFD. Ccdc92 KO significantly inhibited the inflammatory response and suppressed the NLR Family Pyrin Domain Containing 3 (NLRP3) inflammasome in WAT. Altogether, we demonstrated the critical role of CCDC92 in metabolism, constituting a potential target for treating obesity and insulin resistance.
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Affiliation(s)
- Lu Ren
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Wa Du
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Dan Song
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Haocheng Lu
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI 48109, USA
| | - Milton H. Hamblin
- Tulane University Health Sciences Center, Tulane University, New Orleans, LA 70112, USA
- College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA
| | - Chenran Wang
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Chunying Du
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Guo-Chang Fan
- Department of Pharmacology & Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Richard C. Becker
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Yanbo Fan
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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14
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Hjort M, Eggers KM, Lakic TG, Lindbäck J, Budaj A, Cornel JH, Giannitsis E, Katus HA, Siegbahn A, Storey RF, Becker RC, Wallentin L, Lindahl B. Biomarker Concentrations and Their Temporal Changes in Patients With Myocardial Infarction and Nonobstructive Compared With Obstructive Coronary Arteries: Results From the PLATO Trial. J Am Heart Assoc 2022; 12:e027466. [PMID: 36565198 PMCID: PMC9973579 DOI: 10.1161/jaha.122.027466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The pathobiology of myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is often uncertain. Investigating biomarker concentrations and their changes may offer novel pathophysiological insights. Methods and Results In this post hoc study of the PLATO (Platelet Inhibition and Patient Outcomes) trial, concentrations of hs-cTnT (high-sensitivity cardiac troponin T), NT-proBNP (N-terminal pro-B-type natriuretic peptide), hs-CRP (high-sensitivity C-reactive protein), and GDF-15 (growth differentiation factor 15) were measured in patients with MINOCA at baseline (n=554) and at 1-month follow-up (n=107). For comparisons, biomarkers were also measured in patients with MI with obstructive (stenosis ≥50%) coronary artery disease (baseline: n=11 106; follow-up: n=2755]). Adjusted linear regression models were used to compare concentrations and their short- and long-term changes. The adjusted geometric mean ratios (GMRs) in patients with MINOCA (median age, 61 years; 50.4% women) indicated lower hs-cTnT (GMR, 0.77 [95% CI, 0.68-0.88]) but higher hs-CRP (GMR, 1.21 [95% CI, 1.08-1.37]) and GDF-15 concentrations (GMR, 1.06 [95% CI, 1.02-1.11]) at baseline compared with patients with MI with obstructive coronary artery disease, whereas NT-proBNP concentrations were similar. Temporal decreases in hs-cTnT, NT-proBNP, and hs-CRP concentrations until 1-month follow-up were more pronounced in patients with MINOCA. At follow-up, patients with MINOCA had lower concentrations of hs-cTnT (GMR, 0.71 [95% CI, 0.60-0.84]), NT-proBNP (GMR, 0.45 [95% CI, 0.36-0.56]), and hs-CRP (GMR, 0.68 [95% CI, 0.53-0.86]). One-month GDF-15 concentrations were similar between both groups with MI. Conclusions Biomarker concentrations suggest greater initial inflammatory activity, similar degree of myocardial dysfunction, and less pronounced myocardial injury during the acute phase of MINOCA compared with MI with obstructive coronary artery disease but also faster myocardial recovery. Registration URL: http://www.clinicaltrials.gov; Unique identifier: NCT00391872.
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Affiliation(s)
- Marcus Hjort
- Department of Medical SciencesUppsala UniversityUppsalaSweden,Uppsala Clinical Research CenterUppsala UniversityUppsalaSweden
| | - Kai M. Eggers
- Department of Medical SciencesUppsala UniversityUppsalaSweden,Uppsala Clinical Research CenterUppsala UniversityUppsalaSweden
| | | | - Johan Lindbäck
- Uppsala Clinical Research CenterUppsala UniversityUppsalaSweden
| | - Andrzej Budaj
- Department of Cardiology, Centre of Postgraduate Medical EducationGrochowski HospitalWarsawPoland
| | - Jan H. Cornel
- Department of Cardiology, Northwest ClinicsAlkmaar, and Radboud University Medical CenterNijmegenThe Netherlands
| | | | - Hugo A. Katus
- Department of Medicine IIIUniversity of HeidelbergHeidelbergGermany
| | - Agneta Siegbahn
- Department of Medical SciencesUppsala UniversityUppsalaSweden
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular DiseaseUniversity of SheffieldSheffieldUnited Kingdom
| | - Richard C. Becker
- Division of Cardiovascular Health and DiseasesUniversity of Cincinnati Heart, Lung & Vascular InstituteCincinnatiOH
| | - Lars Wallentin
- Department of Medical SciencesUppsala UniversityUppsalaSweden,Uppsala Clinical Research CenterUppsala UniversityUppsalaSweden
| | - Bertil Lindahl
- Department of Medical SciencesUppsala UniversityUppsalaSweden,Uppsala Clinical Research CenterUppsala UniversityUppsalaSweden
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15
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Batra G, Lindbäck J, Becker RC, Harrington RA, Held C, James SK, Kempf T, Lopes RD, Mahaffey KW, Steg PG, Storey RF, Swahn E, Wollert KC, Siegbahn A, Wallentin L. Biomarker-Based Prediction of Recurrent Ischemic Events in Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2022; 80:1735-1747. [PMID: 36302586 DOI: 10.1016/j.jacc.2022.08.767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/15/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with acute coronary syndrome (ACS), there is residual and variable risk of recurrent ischemic events. OBJECTIVES This study aimed to develop biomarker-based prediction models for 1-year risk of cardiovascular (CV) death and myocardial infarction (MI) in patients with ACS undergoing percutaneous coronary intervention. METHODS We included 10,713 patients from the PLATO (A Comparison of Ticagrelor [AZD6140] and Clopidogrel in Patients With Acute Coronary Syndrome) trial in the development cohort and externally validated in 3,508 patients from the TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) trial. Variables contributing to risk of CV death/MI were assessed using Cox regression models, and a score was derived using subsets of variables approximating the full model. RESULTS There were 632 and 190 episodes of CV death/MI in the development and validation cohorts. The most important predictors of CV death/MI were the biomarkers, growth differentiation factor 15, and N-terminal pro-B-type natriuretic peptide, which had greater prognostic value than all candidate variables. The final model included 8 items: age (A), biomarkers (B) (growth differentiation factor 15 and N-terminal pro-B-type natriuretic peptide), and clinical variables (C) (extent of coronary artery disease, previous vascular disease, Killip class, ACS type, P2Y12 inhibitor). The model, named ABC-ACS ischemia, was well calibrated and showed good discriminatory ability for 1-year risk of CV death/MI with C-indices of 0.71 and 0.72 in the development and validation cohorts, respectively. For CV death, the score performed better, with C-indices of 0.80 and 0.84 in the development and validation cohorts, respectively. CONCLUSIONS An 8-item score for the prediction of CV death/MI was developed and validated for patients with ACS undergoing percutaneous coronary intervention. The ABC-ACS ischemia score showed good calibration and discrimination and might be useful for risk prediction and decision support in patients with ACS. (A Comparison of Ticagrelor [AZD6140] and Clopidogrel in Patients With Acute Coronary Syndrome [PLATO]; NCT00391872; Trial to Assess the Effects of Vorapaxar [SCH 530348; MK-5348] in Preventing Heart Attack and Stroke in Participants With Acute Coronary Syndrome [TRACER]; NCT00527943).
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Affiliation(s)
- Gorav Batra
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tibor Kempf
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Renato D Lopes
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Philippe Gabriel Steg
- Université de Paris, Institut National de la Santé et de la Recherche Médicale-Unité 1148, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kai C Wollert
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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16
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Haley JE, Woodly SA, Daniels SR, Falkner B, Ferguson MA, Flynn JT, Hanevold CD, Hooper SR, Ingelfinger JR, Khoury PR, Lande MB, Martin LJ, Meyers KE, Mitsnefes M, Becker RC, Rosner BA, Samuels J, Tran AH, Urbina EM. Association of Blood Pressure-Related Increase in Vascular Stiffness on Other Measures of Target Organ Damage in Youth. Hypertension 2022; 79:2042-2050. [PMID: 35762327 PMCID: PMC9378473 DOI: 10.1161/hypertensionaha.121.18765] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypertension-related increased arterial stiffness predicts development of target organ damage (TOD) and cardiovascular disease. We hypothesized that blood pressure (BP)-related increased arterial stiffness is present in youth with elevated BP and is associated with TOD. METHODS Participants were stratified by systolic BP into low- (systolic BP <75th percentile, n=155), mid- (systolic BP ≥80th and <90th percentile, n=88), and high-risk BP categories (≥90th percentile, n=139), based on age-, sex- and height-specific pediatric BP cut points. Clinic BP, 24-hour ambulatory BP monitoring, anthropometrics, and laboratory data were obtained. Arterial stiffness measures included carotid-femoral pulse wave velocity and aortic stiffness. Left ventricular mass index, left ventricular systolic and diastolic function, and urine albumin/creatinine were collected. ANOVA with Bonferroni correction was used to evaluate differences in cardiovascular risk factors, pulse wave velocity, and cardiac function across groups. General linear models were used to examine factors associated with arterial stiffness and to determine whether arterial stiffness is associated with TOD after accounting for BP. RESULTS Pulse wave velocity increased across groups. Aortic distensibility, distensibility coefficient, and compliance were greater in low than in the mid or high group. Significant determinants of arterial stiffness were sex, age, adiposity, BP, and LDL (low-density lipoprotein) cholesterol. Pulse wave velocity and aortic compliance were significantly associated with TOD (systolic and diastolic cardiac function and urine albumin/creatinine ratio) after controlling for BP. CONCLUSIONS Higher arterial stiffness is associated with elevated BP and TOD in youth emphasizing the need for primary prevention of cardiovascular disease.
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Affiliation(s)
| | - Shalayna A Woodly
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH (S.A.W., P.R.K., L.J.M., M.M., E.M.U.)
| | | | | | | | - Joseph T Flynn
- Department of Pediatrics, University of Washington, Seattle, WA (J.T.F., C.D.H.)
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA (J.T.F., C.D.H.)
| | - Coral D Hanevold
- Department of Pediatrics, University of Washington, Seattle, WA (J.T.F., C.D.H.)
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA (J.T.F., C.D.H.)
| | | | | | - Philip R Khoury
- Rady Children's Hospital San Diego, CA (J.E.H.)
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH (S.A.W., P.R.K., L.J.M., M.M., E.M.U.)
| | - Marc B Lande
- University of Rochester Medical Center, Rochester, NY (M.B.L.)
| | - Lisa J Martin
- Rady Children's Hospital San Diego, CA (J.E.H.)
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH (S.A.W., P.R.K., L.J.M., M.M., E.M.U.)
| | | | - Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH (S.A.W., P.R.K., L.J.M., M.M., E.M.U.)
| | | | | | - Joshua Samuels
- University of Texas Health Sciences Center, Houston (J.S.)
| | - Andrew H Tran
- Nationwide Children's Hospital, Columbus, OH (A.H.T.)
| | - Elaine M Urbina
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH (S.A.W., P.R.K., L.J.M., M.M., E.M.U.)
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17
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Du W, Song D, Ren L, Becker RC, Fan Y. Abstract 101: Genetic Ablation Of CCDC92 Protects Against Vascular Inflammation And Atherosclerosis. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Objective:
Genome-wide association studies (GWAS) have uncovered specific genetic variants of the coiled-coil domain containing 92 (CCDC92) gene that are associated with coronary artery disease (CAD) and type 2 diabetes. However, the biological function of CCDC92 in cardiovascular disease (CVD) remains unclear. This study aims to investigate the impact of CCDC92 on atherosclerosis, a leading cause of CVD, and dissect underlying mechanisms.
Methods and Results:
To investigate the effects of CCDC92 on atherosclerosis development
in vivo
, we used
Ccdc92
knockout (KO) mice and littermate wild type (WT) mice (in
ApoE
KO background) fed a high-cholesterol diet (HCD) for 18 weeks.
Ccdc92
KO significantly reduced atherosclerotic plaque by sixty percent compared with littermate control mice measured by en face analysis of atherosclerotic lesions in the aortic tree after Oil Red O staining (n=11-12/group, p < 0.001). To provide a comprehensive characterization of cellular identity within the atherosclerotic lesion, we applied single-cell sequencing (scRNA-seq) to the whole atherosclerotic aorta from
Ccdc92
KO/
ApoE
KO and littermate control mice on HCD for 12 weeks. The scRNA-seq analysis identified 12 cell subpopulations in the atherosclerotic aorta. Cell-specific gene set enrichment analysis further indicated that Ccdc92 deficiency had protective effects on multiple vascular cell subpopulations. Specifically, in subpopulations of endothelial cells (ECs), CCDC92 regulates cell inflammation and fatty acid metabolism. Using human coronary artery ECs (HCAECs) and mouse aortic EC from
Ccdc92
KO and WT mice, we demonstrated that deletion of CCDC92 significantly inhibited proinflammatory adhesion molecules and cytokines induced by TNF-α. Interestingly, Adenovirus-mediated CCDC92 overexpression increased lipid droplet accumulation (to an average of 4-fold increase) in HCAECs exposed to oleic acid overload.
Conclusions:
Our findings revealed the proatherogenic effects of CCDC92
in vivo
and demonstrated a critical role of CCDC92 in EC dysfunction during atherosclerosis development. These data address an important new mechanism associated with atherosclerosis and provide a potential new target for atherosclerotic disease.
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Affiliation(s)
- Wa Du
- Dept of Cancer Biology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Dan Song
- Dept of Cancer Biology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Lu Ren
- Dept of Cancer Biology, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard C Becker
- Dept of Internal Medicine, Div of Cardiovascular Health and Disease, Univ of Cincinnati College of Medicine, Cincinnati, OH
| | - Yanbo Fan
- Dept of Cancer Biology, Univ of Cincinnati College of Medicine, Cincinnati, OH
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18
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Nelson TA, Parker WAE, Ghukasyan Lakic T, Westerbergh J, James SK, Siegbahn A, Becker RC, Himmelmann A, Wallentin L, Storey RF. Differential effect of clopidogrel and ticagrelor on leukocyte count in relation to patient characteristics, biomarkers and genotype: a PLATO substudy. Platelets 2022; 33:425-431. [PMID: 34077291 DOI: 10.1080/09537104.2021.1934667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022]
Abstract
Inflammation plays a key role in cardiovascular disease by contributing to atherothrombosis. The PLATelet inhibition and patient Outcomes (PLATO) study (NCT00391872) compared ticagrelor to clopidogrel in patients with acute coronary syndromes and demonstrated fewer cardiovascular events with ticagrelor but lower white blood cell counts (WBC) with clopidogrel. In this further analysis of the PLATO biomarker substudy, we assessed associations between WBC and clinical characteristics, biomarker levels, and CYP2C19 polymorphisms.On-treatment mean (SD) WBC in the clopidogrel group was mildly reduced at each stage of follow-up compared with either the ticagrelor group (1 month: 7.27 (2.1) and 7.67 (2.23) x109/L for clopidogrel and ticagrelor, respectively; p < .001) or following cessation of clopidogrel (7.23 (1.97) x109/L, at 6 months vs 7.56 (2.28) x109/L after treatment cessation; P < .001). This occurred independently of baseline biomarkers and CYP2C19 genotype (where known). Adjusting for clinical characteristics and other biomarkers, no significant interaction was detected between clinical risk factors and the observed effect of clopidogrel on WBC.Clopidogrel weakly suppresses WBC, independent of clinical characteristics, baseline inflammatory biomarker levels, and CYP2C19 genotype. Further work is required to determine the mechanism for this effect and whether it contributes to clopidogrel's efficacy as well as therapeutic interaction with anti-inflammatory drugs.
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Affiliation(s)
- Thomas A Nelson
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - William A E Parker
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Tatevik Ghukasyan Lakic
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Johan Westerbergh
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Agneta Siegbahn
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, OH, USA
| | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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19
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Bazrafshan S, Sibilia R, Girgla S, Viswanathan SK, Puckelwartz MJ, Sangha KS, Singh RR, Kakroo M, Jandarov R, Harris DM, Rubinstein J, Becker RC, McNally EM, Sadayappan S. South Asian-Specific MYBPC3 Δ25bp Deletion Carriers Display Hypercontraction and Impaired Diastolic Function Under Exercise Stress. Front Cardiovasc Med 2021; 8:766339. [PMID: 35004883 PMCID: PMC8733148 DOI: 10.3389/fcvm.2021.766339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: A 25-base pair (25bp) intronic deletion in the MYBPC3 gene enriched in South Asians (SAs) is a risk allele for late-onset left ventricular (LV) dysfunction, hypertrophy, and heart failure (HF) with several forms of cardiomyopathy. However, the effect of this variant on exercise parameters has not been evaluated. Methods: As a pilot study, 10 asymptomatic SA carriers of the MYBPC3 Δ25bp variant (52.9 ± 2.14 years) and 10 age- and gender-matched non-carriers (NCs) (50.1 ± 2.7 years) were evaluated at baseline and under exercise stress conditions using bicycle exercise echocardiography and continuous cardiac monitoring. Results: Baseline echocardiography parameters were not different between the two groups. However, in response to exercise stress, the carriers of Δ25bp had significantly higher LV ejection fraction (%) (CI: 4.57 ± 1.93; p < 0.0001), LV outflow tract peak velocity (m/s) (CI: 0.19 ± 0.07; p < 0.0001), and higher aortic valve (AV) peak velocity (m/s) (CI: 0.103 ± 0.08; p = 0.01) in comparison to NCs, and E/A ratio, a marker of diastolic compliance, was significantly lower in Δ25bp carriers (CI: 0.107 ± 0.102; p = 0.038). Interestingly, LV end-diastolic diameter (LVIDdia) was augmented in NCs in response to stress, while it did not increase in Δ25bp carriers (CI: 0.239 ± 0.125; p = 0.0002). Further, stress-induced right ventricular systolic excursion velocity s' (m/s), as a marker of right ventricle function, increased similarly in both groups, but tricuspid annular plane systolic excursion increased more in carriers (slope: 0.008; p = 0.0001), suggesting right ventricle functional differences between the two groups. Conclusions: These data support that MYBPC3 Δ25bp is associated with LV hypercontraction under stress conditions with evidence of diastolic impairment.
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Affiliation(s)
- Sholeh Bazrafshan
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Robert Sibilia
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Saavia Girgla
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Shiv Kumar Viswanathan
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Megan J. Puckelwartz
- Center for Genetic Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Kiranpal S. Sangha
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Rohit R. Singh
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Mashhood Kakroo
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Roman Jandarov
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - David M. Harris
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Jack Rubinstein
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Richard C. Becker
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Elizabeth M. McNally
- Center for Genetic Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Sakthivel Sadayappan
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
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20
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Koh CY, Shih N, Yip CYC, Li AWL, Chen W, Amran FS, Leong EJE, Iyer JK, Croft G, Mazlan MIB, Chee YL, Yap ES, Monroe DM, Hoffman M, Becker RC, de Kleijn DPV, Verma V, Gupta A, Chaudhary VK, Richards AM, Kini RM, Chan MY. Efficacy and safety of next-generation tick transcriptome-derived direct thrombin inhibitors. Nat Commun 2021; 12:6912. [PMID: 34824278 PMCID: PMC8617063 DOI: 10.1038/s41467-021-27275-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 10/28/2021] [Indexed: 01/18/2023] Open
Abstract
Despite their limitations, unfractionated heparin (UFH) and bivalirudin remain standard-of-care parenteral anticoagulants for percutaneous coronary intervention (PCI). We discovered novel direct thrombin inhibitors (DTIs) from tick salivary transcriptomes and optimised their pharmacologic activity. The most potent, ultravariegin, inhibits thrombin with a Ki of 4.0 pM, 445-fold better than bivalirudin. Unexpectedly, despite their greater antithrombotic effect, variegin/ultravariegin demonstrated less bleeding, achieving a 3-to-7-fold wider therapeutic index in rodent thrombosis and bleeding models. When used in combination with aspirin and ticagrelor in a porcine model, variegin/ultravariegin reduced stent thrombosis compared with antiplatelet therapy alone but achieved a 5-to-7-fold lower bleeding time than UFH/bivalirudin. Moreover, two antibodies screened from a naïve human antibody library effectively reversed the anticoagulant activity of ultravariegin, demonstrating proof-of-principle for antidote reversal. Variegin and ultravariegin are promising translational candidates for next-generation DTIs that may reduce peri-PCI bleeding in the presence of antiplatelet therapy.
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Affiliation(s)
- Cho Yeow Koh
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Norrapat Shih
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christina Y. C. Yip
- grid.412106.00000 0004 0621 9599Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Aaron Wei Liang Li
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Weiming Chen
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Fathiah S. Amran
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Esther Jia En Leong
- grid.4280.e0000 0001 2180 6431Department of Biological Sciences, National University of Singapore, Singapore, Singapore
| | - Janaki Krishnamoorthy Iyer
- grid.4280.e0000 0001 2180 6431Department of Biological Sciences, National University of Singapore, Singapore, Singapore
| | - Grace Croft
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Muhammad Ibrahim Bin Mazlan
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yen-Lin Chee
- Department of Haematology, National Cancer Institute, Singapore, Singapore
| | - Eng-Soo Yap
- Department of Haematology, National Cancer Institute, Singapore, Singapore
| | - Dougald M. Monroe
- grid.10698.360000000122483208Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Maureane Hoffman
- grid.26009.3d0000 0004 1936 7961Department of Pathology, Duke University, Durham, NC USA
| | - Richard C. Becker
- grid.24827.3b0000 0001 2179 9593University of Cincinnati, Cincinnati, OH USA
| | - Dominique P. V. de Kleijn
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ,grid.7692.a0000000090126352Department of Vascular Surgery, University Medical Center Utrecht & Netherlands heart Institute, Utrecht, The Netherlands
| | - Vaishali Verma
- grid.8195.50000 0001 2109 4999Centre for Innovation in Infectious Disease Research, Education, and Training (CIIDRET), University of Delhi South Campus, New Delhi, India
| | - Amita Gupta
- grid.8195.50000 0001 2109 4999Centre for Innovation in Infectious Disease Research, Education, and Training (CIIDRET), University of Delhi South Campus, New Delhi, India
| | - Vijay K. Chaudhary
- grid.8195.50000 0001 2109 4999Centre for Innovation in Infectious Disease Research, Education, and Training (CIIDRET), University of Delhi South Campus, New Delhi, India
| | - A. Mark Richards
- grid.410759.e0000 0004 0451 6143Cardiovascular Research Institute, NUHS, Singapore, Singapore ,grid.29980.3a0000 0004 1936 7830Christchurch Heart Institute, University of Otago, Otago, New Zealand
| | - R. Manjunatha Kini
- grid.4280.e0000 0001 2180 6431Department of Biological Sciences, National University of Singapore, Singapore, Singapore ,grid.4280.e0000 0001 2180 6431Department of Pharmacology, Yong Loo-Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Y. Chan
- grid.4280.e0000 0001 2180 6431Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ,grid.488497.e0000 0004 1799 3088Cardiac Department, National University Heart Centre, Singapore, Singapore
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21
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Abstract
Aortic aneurysm, including thoracic aortic aneurysm and abdominal aortic aneurysm, is the second most prevalent aortic disease following atherosclerosis, representing the ninth-leading cause of death globally. Open surgery and endovascular procedures are the major treatments for aortic aneurysm. Typically, thoracic aortic aneurysm has a more robust genetic background than abdominal aortic aneurysm. Abdominal aortic aneurysm shares many features with thoracic aortic aneurysm, including loss of vascular smooth muscle cells (VSMCs), extracellular matrix degradation and inflammation. Although there are limitations to perfectly recapitulating all features of human aortic aneurysm, experimental models provide valuable tools to understand the molecular mechanisms and test novel therapies before human clinical trials. Among the cell types involved in aortic aneurysm development, VSMC dysfunction correlates with loss of aortic wall structural integrity. Here, we discuss the role of VSMCs in aortic aneurysm development. The loss of VSMCs, VSMC phenotypic switching, secretion of inflammatory cytokines, increased matrix metalloproteinase activity, elevated reactive oxygen species, defective autophagy, and increased senescence contribute to aortic aneurysm development. Further studies on aortic aneurysm pathogenesis and elucidation of the underlying signaling pathways are necessary to identify more novel targets for treating this prevalent and clinical impactful disease.
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Affiliation(s)
- Haocheng Lu
- Department of Internal Medicine Cardiovascular Center University of Michigan Medical Center Ann Arbor MI
| | - Wa Du
- Department of Cancer Biology University of Cincinnati College of Medicine Cincinnati OH
| | - Lu Ren
- Department of Cancer Biology University of Cincinnati College of Medicine Cincinnati OH
| | - Milton H Hamblin
- Department of Pharmacology Tulane University School of Medicine New Orleans LA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease Department of Internal Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Y Eugene Chen
- Department of Internal Medicine Cardiovascular Center University of Michigan Medical Center Ann Arbor MI
| | - Yanbo Fan
- Department of Cancer Biology University of Cincinnati College of Medicine Cincinnati OH.,Division of Cardiovascular Health and Disease Department of Internal Medicine University of Cincinnati College of Medicine Cincinnati OH
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22
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Becker RC, Gorog DA. International COVID-19 biomarkers colloquium. J Thromb Thrombolysis 2021; 52:983-984. [PMID: 34735696 PMCID: PMC8567123 DOI: 10.1007/s11239-021-02601-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2021] [Indexed: 11/02/2022]
Affiliation(s)
- Richard C Becker
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College, London, UK.,East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK.,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
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23
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Hjort M, Eggers KM, Becker RC, Budaj A, Cornel JH, Giannitsis E, James SK, Katus HA, Ghukasyan Lakic T, Lindback J, Siegbahn A, Storey RF, Wallentin L, Lindahl B. Temporal changes of biomarkers in myocardial infarction patients with non-obstructive compared to obstructive coronary arteries. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
About 5–10% of all myocardial infarction (MI) patients have non-obstructive coronary arteries (MINOCA). The pathobiology of MINOCA is largely unknown compared to myocardial infarction with obstructive coronaries (MI-CAD).
Purpose
To investigate whether baseline concentrations and temporal changes of circulating biomarkers may offer insights into the activation of pathophysiological pathways in MINOCA compared to MI-CAD.
Methods
From the PLATelet inhibition and patient Outcomes (PLATO) trial, we retrospectively identified 114 patients with MINOCA (adjudicated MI, coronary stenoses <50% and excluding patients with previous coronary revascularization) and 2750 patients with MI-CAD (adjucated MI and stenoses ≥50%) with available biomarker data. Concentrations of high sensitivity cardiac troponin T (hs-cTnT), C-reactive protein (CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were centrally measured by immunoassays in plasma samples obtained at randomization/baseline (median 15 hours from index event) and after one month. Differences in biomarker concentrations and their changes were evaluated by Wilcoxon-Mann-Whitney tests and data at one month were also analysed with adjusted linear regression models.
Results
In MINOCA patients, median concentrations decreased during one month from 238 to 9 ng/L for hs-cTnT, from 3.5 to 1.6 mg/L for CRP and from 507 to 228 pmol/L for NT-proBNP (Figure 1 and 2). In MI-CAD patients, median concentrations decreased from 198 to 13 ng/L for hs-cTnT, from 3.2 to 2.3 mg/L for CRP and increased from 372 to 566 pmol/L for NT-proBNP. Compared to MI-CAD, the baseline concentrations were higher in MINOCA for NT-proBNP (p=0.011), but similar for hs-cTnT (p=0.555) and CRP (p=0.834). However, patients with MINOCA had statistically larger reductions of concentrations from baseline to one month for hs-cTnT (p=0.002), CRP (p=0.005) and NT-proBNP (p<0.001) as compared to patients with MI-CAD. At one month, concentrations were lower in MINOCA than MI-CAD patients for all three biomarkers, which remained significant after adjustment for the baseline biomarker concentration, clinical characteristics and medications (p<0.001).
Conclusions
In MINOCA compared to MI-CAD patients, higher concentrations of NT-proBNP and similar concentrations of hs-cTnT and CRP at baseline indicate a higher degree of acute myocardial dysfunction but similar degree of acute myocardial injury and inflammation. Furthermore, concentrations of these biomarkers were lower at one month in MINOCA, suggesting other or less remaining underlying disease processes after MI in MINOCA than MI-CAD.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): The present study was supported by Swedish Foundation for Strategic Research/Swedish Association of Local Authorities and Regions. The PLATO study and the biomarker analyses were sponsored by AstraZeneca.
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Affiliation(s)
- M Hjort
- Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - K M Eggers
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - R C Becker
- Division of Cardiovascular Health and Diseases, University of Cincinnati Heart, Lung & Vascular Institute, Cincinnati, United States of America
| | - A Budaj
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - J H Cornel
- Department of Cardiology, Northwest Clinics, Alkmaar, and The Radboud University Medical Center, Nijmegen, Netherlands (The)
| | - E Giannitsis
- Department of Medicine III, University of Heidelberg, Heidelberg, Germany
| | - S K James
- Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - H A Katus
- Department of Medicine III, University of Heidelberg, Heidelberg, Germany
| | - T Ghukasyan Lakic
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - J Lindback
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - A Siegbahn
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - R F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - L Wallentin
- Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - B Lindahl
- Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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24
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Carnicelli AP, Hellkamp AS, Mahaffey KW, Singer DE, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Berkowitz SD, Fox KAA, Califf RM, Patel MR. Termination Based on Event Accrual in Per Protocol Versus Intention to Treat in the ROCKET AF Trial. J Am Heart Assoc 2021; 10:e022485. [PMID: 34569249 PMCID: PMC8649140 DOI: 10.1161/jaha.121.022485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background In event‐driven clinical trials, study termination is based on accrual of a target number of primary efficacy events. For noninferiority trials in which superiority is conditionally examined, the ideal cohort in which to track event accrual is unclear. We used data from the ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) trial to determine the effect of primary efficacy‐event tracking in the per‐protocol cohort during the on‐treatment period versus the intention‐to‐treat (ITT) cohort during the ITT period. Methods and Results ROCKET AF was terminated after accruing 429 primary efficacy events (stroke or systemic embolism) in the per‐protocol cohort during the on‐treatment period for noninferiority. We identified the date on which 429 events occurred in the ITT cohort during the ITT period. We performed noninferiority and superiority analyses based on hypothetical study termination on this date. ROCKET AF would have terminated 226 days earlier if events were tracked during the ITT period. Similar to the main trial findings, rivaroxaban would have met noninferiority versus warfarin for the primary efficacy end point (hazard ratio [HR], 0.77; 95% CI, 0.62–0.96; P<0.001). In contrast to the main trial findings, rivaroxaban would have met superiority for the primary efficacy end point (HR, 0.82; 95% CI, 0.68–0.99; P=0.038). In both termination scenarios, rivaroxaban was associated with a lower risk of intracranial hemorrhage and similar risk of other safety end points. Conclusions Clinical trial termination based on event accrual in the ITT cohort versus the per‐protocol cohort may have important implications on trial results depending on rates of study drug discontinuation and event rates off treatment.
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Affiliation(s)
- Anthony P Carnicelli
- Duke Clinical Research Institute Duke University Durham NC.,Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR) Department of Medicine Stanford University School of Medicine Stanford CA
| | - Daniel E Singer
- Division of General Internal Medicine Massachusetts General Hospital Boston MA.,Harvard Medical School Boston MA
| | - Günter Breithardt
- Department of Cardiovascular Medicine University Hospital Münster Münster Germany
| | | | - Graeme J Hankey
- Medical School Faculty of Health and Medical Sciences The University of Western Australia Australia
| | - Jonathan P Piccini
- Duke Clinical Research Institute Duke University Durham NC.,Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
| | - Richard C Becker
- Heart, Lung and Vascular Institute University of Cincinnati College of Medicine Cincinnati OH
| | - Christopher C Nessel
- Janssen Research and DevelopmentJanssenPharmaceutical Companies of Johnson and Johnson Doylestown PA
| | | | - Keith A A Fox
- Division of Medical and Radiological Sciences University of Edinburgh Edinburgh Scotland
| | - Robert M Califf
- Duke Clinical Research Institute Duke University Durham NC.,Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
| | - Manesh R Patel
- Duke Clinical Research Institute Duke University Durham NC.,Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
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25
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Abstract
Abstract The autonomic nervous system (ANS) is a complex network of nerves originating in the brain, brain stem, spinal cord, heart and extracardiac organs that regulates neural and physiological responses to internal and external environments and conditions. A common observation among patients with the 2019 Coronavirus (CoV) (SARS-severe acute respiratory syndrome CoV-2) (SARS-CoV-2) or COVID-19 [CO for corona, VI for virus, D for disease and 19 for when the outbreak was first identified (31 December 2019)] in the acute and chronic phases of the disease is tachycardia, labile blood pressure, muscular fatigue and shortness of breath. Because abnormalities in the ANS can contribute to each of these symptoms, herein a review of autonomic dysfunction in SARS-COV-2 infection is provided to guide diagnostic testing, patient care and research initiatives. Graphic abstract The autonomic nervous system is a complex network of nerves originating in the brain, brain stem, spinal cord, heart and extracardiac organs that regulates neural and physiological responses to internal and external environments and conditions. A common collection of signs and symptoms among patients with the 2019 Coronavirus (CoV) (SARS-severe acute respiratory syndrome CoV-2) (SARS-CoV-2) or COVID-19 [CO for corona, VI for virus, D for disease and 19 for when the outbreak was first identified (31 December 2019)] is tachycardia, labile blood pressure, muscular fatigue and shortness of breath. Abnormalities in the autonomic nervous system (ANS) can contribute to each of these identifiers, potentially offering a unifying pathobiology for acute, subacute and the long-term sequelae of SARS-CoV-2 infection (PASC) and a target for intervention.
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Affiliation(s)
- Richard C Becker
- Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
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26
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Abstract
COVID-19, caused by the SARS-CoV-2 virus, is responsible for a pandemic of unparalleled portion over the past century. While the acute phase of infection causes significant morbidity and mortality, post-acute sequelae that can affect essentially any organ system is rapidly taking on an equally large part of the overall impact on human health, quality of life, attempts to return to normalcy and the global economy. Herein, we summarize the potential role of von Willebrand Factor and extracellular vesicles toward understanding the pathophysiology, clinical presentation, duration of illness, diagnostic approach and management of COVID-19 and its sequelae.
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Affiliation(s)
- Richard C Becker
- Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
| | - Travis Sexton
- The Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Susan Smyth
- University of Arkansas for Medical Sciences, Little Rock, AK, USA
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27
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Blumer V, Rivera M, Corbalán R, Becker RC, Berkowitz SD, Breithardt G, Hacke W, Halperin JL, Hankey GJ, Mahaffey KW, Nessel CC, Piccini JP, Hellkamp AS, Singer DE, Fox KA, Patel MR. Rivaroxaban versus warfarin in patients with atrial fibrillation enrolled in Latin America: Insights from ROCKET AF. Am Heart J 2021; 236:4-12. [PMID: 33571477 DOI: 10.1016/j.ahj.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND ROCKET AF demonstrated the efficacy and safety of rivaroxaban compared with warfarin for the prevention of stroke and systemic embolism (SE) in patients with atrial fibrillation (AF). We examined baseline characteristics and outcomes in patients enrolled in Latin America compared with the rest of the world (ROW). METHODS ROCKET AF enrolled 14,264 patients from 45 countries. Of these, 1,878 (13.2%) were from 7 Latin American countries. The clinical characteristics and outcomes (adjusted by baseline characteristics) of these patients were compared with 12,293 patients from the ROW. Treatment outcomes of rivaroxaban compared with warfarin were also stratified by region. RESULTS The annual rate of stroke/SE was similar in those from Latin American and ROW (P= .63), but all-cause and vascular death were significantly higher than in ROW (HR 1.40, 95% CI 1.20-1.64; HR 1.38, 95% CI 1.14-1.68; P< .001). Rates of major or nonmajor clinically relevant bleeding tended to be lower in Latin America (HR 0.89, 95% CI 0.80-1.0; P= .05). Rates of stroke and/or SE were similar with rivaroxaban and warfarin in patients from Latin America and ROW (HR 0.83, 95% CI 0.54-1.29 vs HR 0.89, 95% CI 0.75-1.07; interaction P= .77). CONCLUSIONS Patients with AF in Latin America had similar rates of stroke and/or SE, higher rates of vascular death, and lower rates of bleeding compared with patients in the ROW. The effect of rivaroxaban compared with warfarin in Latin America was similar to the ROW. Further studies analyzing patient- and country-specific determinants of these regional differences in Latin America are warranted.
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28
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Hamdani G, Mitsnefes MM, Flynn JT, Becker RC, Daniels S, Falkner BE, Ferguson M, Hooper SR, Hanevold CD, Ingelfinger JR, Lande M, Martin LJ, Meyers KE, Rosner B, Samuels J, Urbina EM. Pediatric and Adult Ambulatory Blood Pressure Thresholds and Blood Pressure Load as Predictors of Left Ventricular Hypertrophy in Adolescents. Hypertension 2021; 78:30-37. [PMID: 33966453 DOI: 10.1161/hypertensionaha.120.16896] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Gilad Hamdani
- Schneider Children's Medical Center, Petach Tikvah, Israel (G.H.)
| | - Mark M Mitsnefes
- Schneider Children's Medical Center, Petach Tikvah, Israel (G.H.)
| | - Joseph T Flynn
- Seattle Children's Hospital, Seattle, WA (J.T.F., C.D.H.)
| | | | | | | | | | | | | | | | - Marc Lande
- University of Rochester Medical Center, Rochester, NY (M.L.)
| | - Lisa J Martin
- Schneider Children's Medical Center, Petach Tikvah, Israel (G.H.)
| | | | | | - Joshua Samuels
- University of Texas Health Sciences Center, Houston (J.S.)
| | - Elaine M Urbina
- Schneider Children's Medical Center, Petach Tikvah, Israel (G.H.)
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29
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Santillan MK, Becker RC, Calhoun DA, Cowley AW, Flynn JT, Grobe JL, Kotchen TA, Lackland DT, Leslie KK, Liang M, Mattson DL, Meyers KE, Mitsnefes MM, Muntner PM, Pierce GL, Pollock JS, Sigmund CD, Thomas SJ, Urbina EM, Kidambi S. Team Science: American Heart Association's Hypertension Strategically Focused Research Network Experience. Hypertension 2021; 77:1857-1866. [PMID: 33934625 DOI: 10.1161/hypertensionaha.120.16296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2015, the American Heart Association awarded 4-year funding for a Strategically Focused Research Network focused on hypertension composed of 4 Centers: Cincinnati Children's Hospital, Medical College of Wisconsin, University of Alabama at Birmingham, and University of Iowa. Each center proposed 3 integrated (basic, clinical, and population science) projects around a single area of focus relevant to hypertension. Along with scientific progress, the American Heart Association put a significant emphasis on training of next-generation hypertension researchers by sponsoring 3 postdoctoral fellows per center over 4 years. With the center projects being spread across the continuum of basic, clinical, and population sciences, postdoctoral fellows were expected to garner experience in various types of research methodologies. The American Heart Association also provided a number of leadership development opportunities for fellows and investigators in these centers. In addition, collaboration was highly encouraged among the centers (both within and outside the network) with the American Heart Association providing multiple opportunities for meeting and expanding associations. The area of focus for the Cincinnati Children's Hospital Center was hypertension and target organ damage in children utilizing ambulatory blood pressure measurements. The Medical College of Wisconsin Center focused on epigenetic modifications and their role in pathogenesis of hypertension using human and animal studies. The University of Alabama at Birmingham Center's areas of research were diurnal blood pressure patterns and clock genes. The University of Iowa Center evaluated copeptin as a possible early biomarker for preeclampsia and vascular endothelial function during pregnancy. In this review, challenges faced and successes achieved by the investigators of each of the centers are presented.
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Affiliation(s)
- Mark K Santillan
- Obstetrics/Gynecology (M.K.S.,K.K.L), University of Iowa, Iowa City, IA
| | - Richard C Becker
- Internal Medicine (R.C.B.), Cincinnati Children's Hospital, Cincinnati, OH
| | - David A Calhoun
- Internal Medicine (D.A.C., J.S.P.), University of Alabama at Birmingham, AL
| | - Allen W Cowley
- Physiology (A.W.C., J.L.G., M.L., C.D.S.), Medical College of Wisconsin, Milwaukee, WI
| | | | - Justin L Grobe
- Physiology (A.W.C., J.L.G., M.L., C.D.S.), Medical College of Wisconsin, Milwaukee, WI
| | - Theodore A Kotchen
- Internal Medicine (T.A.K., S.K.), Medical College of Wisconsin, Milwaukee, WI
| | - Daniel T Lackland
- Neurology, Medical University of South Carolina, Charleston, SC (D.T.L.)
| | - Kimberly K Leslie
- Obstetrics/Gynecology (M.K.S.,K.K.L), University of Iowa, Iowa City, IA
| | - Mingyu Liang
- Physiology (A.W.C., J.L.G., M.L., C.D.S.), Medical College of Wisconsin, Milwaukee, WI
| | - David L Mattson
- Physiology, Medical College of Georgia, Augusta, GA (D.L.M.)
| | - Kevin E Meyers
- Pediatrics, Children's Hospital of Philadelphia, PA (K.E.M.)
| | - Mark M Mitsnefes
- Pediatrics (M.M.M., E.M.U), Cincinnati Children's Hospital, Cincinnati, OH
| | - Paul M Muntner
- Epidemiology (P.M.M.), University of Alabama at Birmingham, AL
| | - Gary L Pierce
- Health and Human Physiology (G.L.P), University of Iowa, Iowa City, IA
| | - Jennifer S Pollock
- Internal Medicine (D.A.C., J.S.P.), University of Alabama at Birmingham, AL
| | - Curt D Sigmund
- Physiology (A.W.C., J.L.G., M.L., C.D.S.), Medical College of Wisconsin, Milwaukee, WI
| | | | - Elaine M Urbina
- Pediatrics (M.M.M., E.M.U), Cincinnati Children's Hospital, Cincinnati, OH
| | - Srividya Kidambi
- Internal Medicine (T.A.K., S.K.), Medical College of Wisconsin, Milwaukee, WI
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30
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Ugowe FE, Hellkamp AS, Wang A, Becker RC, Berkowitz SD, Breithardt G, Fox KAA, Halperin JL, Hankey GJ, Mahaffey KW, Nessel CC, Singer DE, Patel MR, Piccini JP. Pharmacotherapy for diabetes and stroke risk: Results from ROCKET AF. Heart Rhythm O2 2021; 2:215-222. [PMID: 34337571 PMCID: PMC8322824 DOI: 10.1016/j.hroo.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Insulin use may be a better predictor of stroke risk and morbidity and mortality than diabetes in patients with atrial fibrillation (AF). Objectives Determine if the increased risk of stroke observed in patients with AF and diabetes is restricted to those treated with insulin. Methods We analyzed the association between diabetes and treatment and the occurrence of stroke/systemic embolism, myocardial infarction (MI), all-cause death, vascular death, composite outcomes, and bleeding risk in the ROCKET AF trial. Results In a cohort of 14,264 patients, there were 40.3% (n = 5746) with diabetes, 5.9% (n = 842) on insulin, 18.9% (n = 2697) on oral medications, and 11.9% (n = 1703) diet-controlled. Compared to those without diabetes, patients with non–insulin-treated diabetes had increased risks of stroke (hazard ratio [HR] 1.33, 95% confidence interval [CI] 1.06–1.68), MI (HR 1.64, 95% CI 1.17–2.30), all-cause death (HR 1.26, 95% CI 1.08–1.46), vascular death (HR 1.33, 95% CI 1.11–1.60), and composite outcomes (HR 1.37, 95% CI 1.18–1.157). Patients with insulin-treated diabetes had a significantly higher risk of MI (HR 2.31, 95% CI 1.33–4.01) and composite outcomes (HR 1.57, 95% CI 1.19–2.08) compared to those without diabetes. There were no significant differences between insulin-treated and non–insulin-treated diabetes for any outcome. Conclusion Among patients with AF and diabetes, there were no significant differences in outcomes in insulin-treated diabetes compared to non–insulin-treated diabetes.
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Affiliation(s)
- Francis E Ugowe
- Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Allen Wang
- Duke Center for Atrial Fibrillation, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Keith A A Fox
- University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | | | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, Australia
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University, School of Medicine, Stanford, California
| | | | - Daniel E Singer
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Manesh R Patel
- Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jonathan P Piccini
- Duke University Medical Center, Duke University School of Medicine, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Bazrafshan S, Kushlaf H, Kakroo M, Quinlan J, Becker RC, Sadayappan S. Genetic Modifiers of Hereditary Neuromuscular Disorders and Cardiomyopathy. Cells 2021; 10:cells10020349. [PMID: 33567613 PMCID: PMC7915259 DOI: 10.3390/cells10020349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/26/2021] [Accepted: 02/03/2021] [Indexed: 12/18/2022] Open
Abstract
Novel genetic variants exist in patients with hereditary neuromuscular disorders (NMD), including muscular dystrophy. These patients also develop cardiac manifestations. However, the association between these gene variants and cardiac abnormalities is understudied. To determine genetic modifiers and features of cardiac disease in NMD patients, we have reviewed electronic medical records of 651 patients referred to the Muscular Dystrophy Association Care Center at the University of Cincinnati and characterized the clinical phenotype of 14 patients correlating with their next-generation sequencing data. The data were retrieved from the electronic medical records of the 14 patients included in the current study and comprised neurologic and cardiac phenotype and genetic reports which included comparative genomic hybridization array and NGS. Novel associations were uncovered in the following eight patients diagnosed with Limb-girdle Muscular Dystrophy, Bethlem Myopathy, Necrotizing Myopathy, Charcot-Marie-Tooth Disease, Peripheral Polyneuropathy, and Valosin-containing Protein-related Myopathy. Mutations in COL6A1, COL6A3, SGCA, SYNE1, FKTN, PLEKHG5, ANO5, and SMCHD1 genes were the most common, and the associated cardiac features included bundle branch blocks, ventricular chamber dilation, septal thickening, and increased outflow track gradients. Our observations suggest that features of cardiac disease and modifying gene mutations in patients with NMD require further investigation to better characterize genotype–phenotype relationships.
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Affiliation(s)
- Sholeh Bazrafshan
- Heart, Lung and Vascular Institute, Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (S.B.); (M.K.); (R.C.B.)
| | - Hani Kushlaf
- Department of Neurology and Rehabilitation Medicine, Neuromuscular Center, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (H.K.); (J.Q.)
| | - Mashhood Kakroo
- Heart, Lung and Vascular Institute, Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (S.B.); (M.K.); (R.C.B.)
| | - John Quinlan
- Department of Neurology and Rehabilitation Medicine, Neuromuscular Center, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (H.K.); (J.Q.)
| | - Richard C. Becker
- Heart, Lung and Vascular Institute, Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (S.B.); (M.K.); (R.C.B.)
| | - Sakthivel Sadayappan
- Heart, Lung and Vascular Institute, Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA; (S.B.); (M.K.); (R.C.B.)
- Correspondence: ; Tel.: +1-513-558-7498
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Abstract
COVID-19- related patient care and research have focused on short-term outcomes, particularly among those with underlying or preexisting medical conditions. A major focus has been on mortality rates. Broadening the dialogue is neither meant nor intended to disparage the near-term devastation felt globally each day, but rather to begin preparation for optimally caring for and addressing the needs of survivors. The sequelae of COVID-19 includes acute, subacute and chronic stages of the condition. If one applies current World Health Organization (WHO) statistics to calculate the global burden of disease, there are 98,000,000 COVID-19 survivors. The following editorial focuses on post-COVID sequelae as a continuum of patient care needs, as well as discovery and training opportunities in an academic setting.
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Affiliation(s)
- Richard C Becker
- Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
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Kumar M, Thangavel C, Becker RC, Sadayappan S. Monoclonal Antibody-Based Immunotherapy and Its Role in the Development of Cardiac Toxicity. Cancers (Basel) 2020; 13:E86. [PMID: 33396766 PMCID: PMC7795565 DOI: 10.3390/cancers13010086] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/22/2020] [Accepted: 12/26/2020] [Indexed: 12/14/2022] Open
Abstract
Immunotherapy is one of the most effective therapeutic options for cancer patients. Five specific classes of immunotherapies, which includes cell-based chimeric antigenic receptor T-cells, checkpoint inhibitors, cancer vaccines, antibody-based targeted therapies, and oncolytic viruses. Immunotherapies can improve survival rates among cancer patients. At the same time, however, they can cause inflammation and promote adverse cardiac immune modulation and cardiac failure among some cancer patients as late as five to ten years following immunotherapy. In this review, we discuss cardiotoxicity associated with immunotherapy. We also propose using human-induced pluripotent stem cell-derived cardiomyocytes/ cardiac-stromal progenitor cells and cardiac organoid cultures as innovative experimental model systems to (1) mimic clinical treatment, resulting in reproducible data, and (2) promote the identification of immunotherapy-induced biomarkers of both early and late cardiotoxicity. Finally, we introduce the integration of omics-derived high-volume data and cardiac biology as a pathway toward the discovery of new and efficient non-toxic immunotherapy.
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Affiliation(s)
- Mohit Kumar
- Heart, Lung and Vascular Institute, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH 45267, USA; (R.C.B.); (S.S.)
| | - Chellappagounder Thangavel
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA;
- Department of Dermatology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Richard C. Becker
- Heart, Lung and Vascular Institute, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH 45267, USA; (R.C.B.); (S.S.)
| | - Sakthivel Sadayappan
- Heart, Lung and Vascular Institute, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH 45267, USA; (R.C.B.); (S.S.)
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Abstract
Background Hypertrophic cardiomyopathy (HCM) is a genetic disease of the heart and the most common cause of sudden cardiac death in the young. HCM is considered a disease of the sarcomere owing to the large number of mutations in genes encoding sarcomeric proteins. The riddle lies in discovering how these mutations lead to disease. As a result, treatments to prevent and/or treat HCM are limited to invasive surgical myectomies or ablations. The A31P variant of cardiac myosin binding protein-C, encoded by MYBPC3, was found to be more prevalent in a cohort of Maine Coon cats with HCM. However, other mutations in MYBPC3 and MYH7 have also been associated with HCM in cats of other breeds. In this study, we expand the spectrum of genes associated with HCM in cats. Results Next Generation Whole Genome sequencing was performed using DNA isolated from peripheral blood of a Maine Coon with cardiomyopathy that tested negative for the MYBPC3 A31P variant. Through risk stratification of variants, we identified a novel, homozygous intronic variant in cardiac troponin T (TNNT2). In silico analysis of the variant suggested that it may affect normal splicing of exon 3 of TNNT2. Both parents tested heterozygous for the mutation, but were unaffected by the disease. Echocardiography analyses revealed that the proband had shown early onset congestive heart failure, which is managed with a treatment regime including ACE and aldosterone inhibitors. Conclusion In summary, we are the first to demonstrate the association between TNNT2 mutations and HCM in felines, suggesting that this gene should be included in the testing panel of genes when performing genetic testing for HCM in cats.
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Affiliation(s)
- James W McNamara
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, Cincinnati, OH, United States
| | - Maggie Schuckman
- Department of Cardiology, MedVet Cincinnati, Fairfax, OH, United States
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, Cincinnati, OH, United States
| | - Sakthivel Sadayappan
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, Cincinnati, OH, United States
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McNamara JW, Schuckman M, Becker RC, Sadayappan S. A Novel Homozygous Intronic Variant in TNNT2 Associates With Feline Cardiomyopathy. Front Physiol 2020; 11:608473. [PMID: 33304277 PMCID: PMC7701303 DOI: 10.3389/fphys.2020.608473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 10/26/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is a genetic disease of the heart and the most common cause of sudden cardiac death in the young. HCM is considered a disease of the sarcomere owing to the large number of mutations in genes encoding sarcomeric proteins. The riddle lies in discovering how these mutations lead to disease. As a result, treatments to prevent and/or treat HCM are limited to invasive surgical myectomies or ablations. The A31P variant of cardiac myosin binding protein-C, encoded by MYBPC3, was found to be more prevalent in a cohort of Maine Coon cats with HCM. However, other mutations in MYBPC3 and MYH7 have also been associated with HCM in cats of other breeds. In this study, we expand the spectrum of genes associated with HCM in cats. RESULTS Next Generation Whole Genome sequencing was performed using DNA isolated from peripheral blood of a Maine Coon with cardiomyopathy that tested negative for the MYBPC3 A31P variant. Through risk stratification of variants, we identified a novel, homozygous intronic variant in cardiac troponin T (TNNT2). In silico analysis of the variant suggested that it may affect normal splicing of exon 3 of TNNT2. Both parents tested heterozygous for the mutation, but were unaffected by the disease. Echocardiography analyses revealed that the proband had shown early onset congestive heart failure, which is managed with a treatment regime including ACE and aldosterone inhibitors. CONCLUSION In summary, we are the first to demonstrate the association between TNNT2 mutations and HCM in felines, suggesting that this gene should be included in the testing panel of genes when performing genetic testing for HCM in cats.
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Affiliation(s)
- James W. McNamara
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, Cincinnati, OH, United States
| | - Maggie Schuckman
- Department of Cardiology, MedVet Cincinnati, Fairfax, OH, United States
| | - Richard C. Becker
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, Cincinnati, OH, United States
| | - Sakthivel Sadayappan
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, Cincinnati, OH, United States
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Affiliation(s)
- Richard C Becker
- Department of Medicine, University of Cincinnati Heart and Circulation Research Institute, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
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37
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Affiliation(s)
- Richard C Becker
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, University of Cincinnati Heart, Lung and Vascular Institute, Cincinnati, Ohio.
| | - Sakthivel Sadayappan
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, University of Cincinnati Heart, Lung and Vascular Institute, Cincinnati, Ohio. https://twitter.com/sadayappanlab
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Abstract
PURPOSE OF REVIEW The management of patients with mechanical heart valves who require surgery or invasive procedures is a common clinical scenario in contemporary practice. The risk of thromboembolism versus the risk of bleeding is the foundation of optimal patient care. RECENT FINDINGS Randomized, controlled trials are not available; yet, there is a wealth of experience to guide best practice. Current guidelines represent a compilation of data from trials of atrial fibrillation and expert opinion. Results from the PERI-OP trial of patients with either a mechanical heart valve, atrial fibrillation, or atrial flutter requiring interruption of oral anticoagulant therapy for surgery will inform clinical practice. Patient-specific factors and valve-specific factors are paramount when deciding whether a period of anticoagulant therapy interruption is safe. Similarly, the safety and efficacy of bridging anticoagulant therapy and the optimal time after surgery for restarting oral anticoagulants is vital to optimal patient care.
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Affiliation(s)
- Mahboob Ali
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0542, CVC, Room 4936, Cincinnati, OH, 45267-0542, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0542, CVC, Room 4936, Cincinnati, OH, 45267-0542, USA.
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Jawitz OK, Wang TY, Lopes RD, Chavez A, Boyer B, Kim H, Anstrom KJ, Becker RC, Blackstone E, Ruel M, Thourani VH, Puskas JD, Gerdisch MW, Johnston D, Capps S, Alexander JH, Svensson LG. Rationale and design of PROACT Xa: A randomized, multicenter, open-label, clinical trial to evaluate the efficacy and safety of apixaban versus warfarin in patients with a mechanical On-X Aortic Heart Valve. Am Heart J 2020; 227:91-99. [PMID: 32693197 DOI: 10.1016/j.ahj.2020.06.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/16/2020] [Indexed: 12/16/2022]
Abstract
Vitamin K antagonists are the only approved oral anticoagulants for long-term prophylaxis against valve thrombosis and thromboembolism in patients with a mechanical heart valve. Despite the proven efficacy and safety of anticoagulation with the oral direct factor Xa inhibitor apixaban compared with warfarin in high-risk populations including subjects with atrial fibrillation or with venous thromboembolism, it remains unknown whether patients with a mechanical heart valve can be safely managed with apixaban. The On-X Aortic Heart Valve and On-X Ascending Aortic Prosthesis with the Vascutek Gelweave Valsalva Graft may have lower rates of valve thrombosis and thromboembolism than conventional bileaflet and tilting disc valves due its unique pyrolytic carbon composition and flared inlet design. DESIGN: PROACT Xa is a randomized, multicenter, open-label, active-controlled trial comparing apixaban with warfarin in patients with an On-X Aortic Heart Valve or On-X Ascending Aortic Prosthesis with the Vascutek Gelweave Valsalva Graft. The study will randomize approximately 1,000 patients from approximately 60 sites in North America who underwent aortic valve replacement at least 3 months prior. Patients will be randomized 1:1 to receiving apixaban 5 mg twice daily or warfarin with a target international normalized ratio of 2.0-3.0. The last randomized participant will be followed for at least 2 years. The primary efficacy outcome is the composite of valve thrombosis and valve-related thromboembolism, and the primary safety outcome is major bleeding. Assuming the primary outcome occurs in warfarin-anticoagulated patients at a rate of 1.75%/patient-year, the study has more than 90% power to assess noninferiority of apixaban treatment with an absolute noninferiority margin of 1.75%/patient-year. A second co-primary analysis is to compare the hazard rate for the apixaban arm to twice the objective performance criterion for thromboembolism and valve thrombosis, that is, 3.4%/patient-year. SUMMARY: PROACT Xa will determine whether patients with an On-X Aortic Heart Valve can be anticoagulated with apixaban as an alternative to warfarin.
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Gregersen I, Michelsen AE, Lunde NN, Åkerblom A, Lakic TG, Skjelland M, Ryeng Skagen K, Becker RC, Lindbäck J, Himmelmann A, Solberg R, Johansen HT, James SK, Siegbahn A, Storey RF, Kontny F, Aukrust P, Ueland T, Wallentin L, Halvorsen B. Legumain in Acute Coronary Syndromes: A Substudy of the PLATO (Platelet Inhibition and Patient Outcomes) Trial. J Am Heart Assoc 2020; 9:e016360. [PMID: 32809893 PMCID: PMC7660754 DOI: 10.1161/jaha.120.016360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The cysteine protease legumain is increased in patients with atherosclerosis, but its causal role in atherogenesis and cardiovascular disease is still unclear. The aim of the study was to investigate the association of legumain with clinical outcome in a large cohort of patients with acute coronary syndrome. Methods and Results Serum levels of legumain were analyzed in 4883 patients with acute coronary syndrome from a substudy of the PLATO (Platelet Inhibition and Patient Outcomes) trial. Levels were analyzed at admission and after 1 month follow-up. Associations between legumain and a composite of cardiovascular death, spontaneous myocardial infarction or stroke, and its individual components were assessed by multivariable Cox regression analyses. At baseline, a 50% increase in legumain level was associated with a hazard ratio (HR) of 1.13 (95% CI, 1.04-1.21), P=0.0018, for the primary composite end point, adjusted for randomized treatment. The association remained significant after adjustment for important clinical and demographic variables (HR, 1.10; 95% CI, 1.02-1.19; P=0.013) but not in the fully adjusted model. Legumain levels at 1 month were not associated with the composite end point but were negatively associated with stroke (HR, 0.62; 95% CI, 0.44-0.88; P=0.0069), including in the fully adjusted model (HR, 0.57; 95% CI, 0.37-0.88; P=0.0114). Conclusions Baseline legumain was associated with the primary outcome in patients with acute coronary syndrome, but not in the fully adjusted model. The association between high levels of legumain at 1 month and decreased occurrence of stroke could be of interest from a mechanistic point of view, illustrating the potential dual role of legumain during atherogenesis and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00391872.
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Affiliation(s)
- Ida Gregersen
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway
| | - Annika E Michelsen
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway
| | - Ngoc Nguyen Lunde
- Section of Pharmacology and Pharmaceutical Biosciences Department of Pharmacy University of Oslo Norway
| | - Axel Åkerblom
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Tatevik G Lakic
- Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Mona Skjelland
- Department of Neurology Oslo University Hospital Rikshospitalet Oslo Norway
| | | | - Richard C Becker
- Division of Cardiovascular Health and Disease Heart, Lung and Vascular Institute Academic Health Center Cincinnati OH
| | - Johan Lindbäck
- Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | | | - Rigmor Solberg
- Section of Pharmacology and Pharmaceutical Biosciences Department of Pharmacy University of Oslo Norway
| | - Harald T Johansen
- Section of Pharmacology and Pharmaceutical Biosciences Department of Pharmacy University of Oslo Norway
| | - Stefan K James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease University of Sheffield Sheffield United Kingdom
| | - Frederic Kontny
- Department of Cardiology Stavanger University Hospital Stavanger Norway.,Drammen Heart Center Drammen Norway
| | - Pål Aukrust
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway.,Section of Clinical Immunology and Infectious Diseases Oslo University Hospital Rikshospitalet Oslo Norway.,K.G. Jebsen TREC The Faculty of Health Sciences The Arctic University of Tromsø Tromsø Norway
| | - Thor Ueland
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway.,K.G. Jebsen TREC The Faculty of Health Sciences The Arctic University of Tromsø Tromsø Norway
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Bente Halvorsen
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway
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Arif M, Nabavizadeh P, Song T, Desai D, Singh R, Bazrafshan S, Kumar M, Wang Y, Gilbert RJ, Dhandapany PS, Becker RC, Kranias EG, Sadayappan S. Genetic, clinical, molecular, and pathogenic aspects of the South Asian-specific polymorphic MYBPC3 Δ25bp variant. Biophys Rev 2020; 12:1065-1084. [PMID: 32656747 PMCID: PMC7429610 DOI: 10.1007/s12551-020-00725-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 02/06/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a cardiac genetic disease characterized by ventricular enlargement, diastolic dysfunction, and increased risk for sudden cardiac death. Sarcomeric genetic defects are the predominant known cause of HCM. In particular, mutations in the myosin-binding protein C gene (MYBPC3) are associated with ~ 40% of all HCM cases in which a genetic basis has been established. A decade ago, our group reported a 25-base pair deletion in intron 32 of MYBPC3 (MYBPC3Δ25bp) that is uniquely prevalent in South Asians and is associated with autosomal dominant cardiomyopathy. Although our studies suggest that this deletion results in left ventricular dysfunction, cardiomyopathies, and heart failure, the precise mechanism by which this variant predisposes to heart disease remains unclear. Increasingly appreciated, however, is the contribution of secondary risk factors, additional mutations, and lifestyle choices in augmenting or modifying the HCM phenotype in MYBPC3Δ25bp carriers. Therefore, the goal of this review article is to summarize the current research dedicated to understanding the molecular pathophysiology of HCM in South Asians with the MYBPC3Δ25bp variant. An emphasis is to review the latest techniques currently applied to explore the MYBPC3Δ25bp pathogenesis and to provide a foundation for developing new diagnostic strategies and advances in therapeutics.
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Affiliation(s)
- Mohammed Arif
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA.
| | - Pooneh Nabavizadeh
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA
| | - Taejeong Song
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA
| | - Darshini Desai
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA
| | - Rohit Singh
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA
| | - Sholeh Bazrafshan
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA
| | - Mohit Kumar
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA
| | - Yigang Wang
- Department of Pathology and Laboratory Medicine, University of Cincinnati, College of Medicine, Cincinnati, OH, 45267, USA
| | - Richard J Gilbert
- Research Service, Providence VA Medical Center, Providence, RI, 02908, USA
| | - Perundurai S Dhandapany
- Centre for Cardiovascular Biology and Disease, Institute for Stem Cell Biology and Regenerative Medicine (inStem), Bangalore, India
- The Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
- Department of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA
| | - Evangelia G Kranias
- Department of Pharmacology and Systems Physiology, University of Cincinnati, College of Medicine, Cincinnati, OH, 45267, USA
| | - Sakthivel Sadayappan
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, Heart, Lung and Vascular Institute, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267-0575, USA
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Abstract
Studies using whole blood platelet aggregometry as a laboratory research tool, provided important insights into the mechanism and modulators of platelet aggregation. Subsequently, a number of point-of-care (POC) platelet function tests (PFTs) were developed for clinical use, based on the concept that an individual’s thrombotic profile could be assessed in vitro by assessing the response to stimulation of platelet aggregation by specific, usually solo agonists such as adenosine diphosphate (ADP), collagen and thrombin. However, adjusting antiplatelet medication in order to improve the results of such POC PFTs has not translated into a meaningful reduction in cardiovascular events, which may be attributable to important differences between the POC PFT techniques and in vivo conditions, including patient-to-patient variability. Important limitations of most tests include the use of citrate-anticoagulated blood. Citrate directly and irreversibly diminishes platelet function and even after recalcification, it may result in altered platelet aggregation in response to ADP, epinephrine or collagen, and interfere with thrombin generation from activated platelets. Furthermore, most tests do not employ flowing blood and therefore do not assess the effect of high shear forces on platelets that initiate, propagate and stabilize arterial thrombi. Finally, the effect of endogenous thrombolysis, due to fibrinolysis and dislodgement, which ultimately determines the outcome of a thrombotic stimulus, is mostly not assessed. In order to accurately reflect an individual’s predisposition to arterial thrombosis, future tests of thrombotic status which overcome these limitations should be used, to improve cardiovascular risk prediction and to guide pharmacotherapy.
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Affiliation(s)
- Diana A Gorog
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK.
- University of Hertfordshire, Hertfordshire, UK.
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45
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Becker RC, Phillip Owens A, Sadayappan S. The potential roles of Von Willebrand factor and neutrophil extracellular traps in the natural history of hypertrophic and hypertensive cardiomyopathy. Thromb Res 2020; 192:78-87. [PMID: 32460175 DOI: 10.1016/j.thromres.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 05/01/2020] [Accepted: 05/03/2020] [Indexed: 02/09/2023]
Abstract
Inflammation is often applied broadly to human disease. Despite its general familiarity, inflammation is highly complex. There are numerous injurious, immune and infectious determinants, functional elements and signaling pathways, ranging from genetic to epigenetic, environmental, racial, molecular and cellular that participate in disease onset and progression, phenotypic heterogeneity, and treatment selection and response. In addition, inflammation can be tissue and organ specific, adding a layer of complexity to achieving a detailed and translatable understanding of its role in health and disease. The following review takes a close look at inflammation in the context of two common heart diseases, hypertrophic cardiomyopathy and hypertensive cardiomyopathy.
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Affiliation(s)
- Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Blood Institute, University of Cincinnati College of Medicine, United States of America.
| | - A Phillip Owens
- Division of Cardiovascular Health and Disease, Heart, Lung and Blood Institute, University of Cincinnati College of Medicine, United States of America
| | - Sakthivel Sadayappan
- Division of Cardiovascular Health and Disease, Heart, Lung and Blood Institute, University of Cincinnati College of Medicine, United States of America
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46
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Tran AH, Flynn JT, Becker RC, Daniels SR, Falkner BE, Ferguson M, Hanevold CD, Hooper SR, Ingelfinger JR, Lande MB, Martin LJ, Meyers K, Mitsnefes M, Rosner B, Samuels JA, Urbina EM. Subclinical Systolic and Diastolic Dysfunction Is Evident in Youth With Elevated Blood Pressure. Hypertension 2020; 75:1551-1556. [PMID: 32362230 PMCID: PMC7266265 DOI: 10.1161/hypertensionaha.119.14682] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hypertension is associated with cardiovascular events in adults. Subclinical changes to left ventricular strain and diastolic function have been found before development of decreased left ventricular ejection fraction and cardiovascular events. Our objective was to study effects of blood pressure (BP) on ventricular function in youth across the BP spectrum. Vital signs and labs were obtained in 346 participants aged 11 to 19 years who had BP categorized as low-risk (N=144; systolic BP <75th percentile), mid-risk (N=83; systolic BP ≥80th and <90th percentile), and high-risk (N=119; systolic BP ≥90th percentile). Echocardiography was performed to assess left ventricular strain and diastolic function. Differences between groups were analyzed by ANOVA. General linear models were constructed to determine independent predictors of systolic and diastolic function. Mid-risk and high-risk participants had greater adiposity and more adverse metabolic labs (lower HDL [high-density lipoprotein], higher glucose, and higher insulin) than the low-risk group. Mid-risk and high-risk participants had significantly lower left ventricular ejection fraction and peak global longitudinal strain than the low-risk group (both P≤0.05). The E/e' ratio was higher in the high-risk group versus the low-risk and mid-risk groups, and the e'/a' ratio was lower in the high-risk versus the low-risk group (both P≤0.05). BP and adiposity were statistically significant determinants of left ventricular systolic and diastolic function. Subclinical changes in left ventricular systolic and diastolic function can be detected even at BP levels below the hypertensive range as currently defined.
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Affiliation(s)
- Andrew H Tran
- From the Cincinnati Children's Hospital Medical Center, OH (A.H.T., L.J.M., M.M., E.M.U.).,University of Cincinnati, OH (A.H.T., R.C.B., L.J.M., M.M., E.M.U.).,The Ohio State University, OH (A.H.T.).,Nationwide Children's Hospital, Columbus, OH (A.H.T.)
| | | | - Richard C Becker
- University of Cincinnati, OH (A.H.T., R.C.B., L.J.M., M.M., E.M.U.)
| | | | | | | | | | - Stephen R Hooper
- School of Medicine, University of North Carolina at Chapel Hill (S.R.H.)
| | | | - Marc B Lande
- University of Rochester Medical Center, New York (M.B.L.)
| | - Lisa J Martin
- From the Cincinnati Children's Hospital Medical Center, OH (A.H.T., L.J.M., M.M., E.M.U.).,University of Cincinnati, OH (A.H.T., R.C.B., L.J.M., M.M., E.M.U.)
| | | | - Mark Mitsnefes
- From the Cincinnati Children's Hospital Medical Center, OH (A.H.T., L.J.M., M.M., E.M.U.).,University of Cincinnati, OH (A.H.T., R.C.B., L.J.M., M.M., E.M.U.)
| | | | | | - Elaine M Urbina
- From the Cincinnati Children's Hospital Medical Center, OH (A.H.T., L.J.M., M.M., E.M.U.).,University of Cincinnati, OH (A.H.T., R.C.B., L.J.M., M.M., E.M.U.)
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47
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Becker RC. Elite Reviewers 2019. J Thromb Thrombolysis 2020; 49:685-686. [DOI: 10.1007/s11239-020-02099-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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48
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Becker KC, Kwee LC, Neely ML, Grass E, Jakubowski JA, Fox KAA, White HD, Gregory SG, Gurbel PA, Carvalho LDP, Becker RC, Magnus Ohman E, Roe MT, Shah SH, Chan MY. Circulating MicroRNA Profiling in Non-ST Elevated Coronary Artery Syndrome Highlights Genomic Associations with Serial Platelet Reactivity Measurements. Sci Rep 2020; 10:6169. [PMID: 32277149 PMCID: PMC7148370 DOI: 10.1038/s41598-020-63263-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 03/24/2020] [Indexed: 12/12/2022] Open
Abstract
Changes in platelet physiology are associated with simultaneous changes in microRNA concentrations, suggesting a role for microRNA in platelet regulation. Here we investigated potential associations between microRNA and platelet reactivity (PR), a marker of platelet function, in two cohorts following a non-ST elevation acute coronary syndrome (NSTE-ACS) event. First, non-targeted microRNA concentrations and PR were compared in a case (N = 77) control (N = 76) cohort within the larger TRILOGY-ACS trial. MicroRNA significant in this analysis plus CVD-associated microRNAs from the literature were then quantified by targeted rt-PCR in the complete TRILOGY-ACS cohort (N = 878) and compared with matched PR samples. Finally, microRNA significant in the non-targeted & targeted analyses were verified in an independent post NSTE-ACS cohort (N = 96). From the non-targeted analysis, 14 microRNAs were associated with PR (Fold Change: 0.91–1.27, p-value: 0.004–0.05). From the targeted analysis, five microRNAs were associated with PR (Beta: −0.09–0.22, p-value: 0.004–0.05). Of the 19 significant microRNAs, three, miR-15b-5p, miR-93 and miR-126, were consistently associated with PR in the TRILOGY-ACS and independent Singapore post-ACS cohorts, suggesting the measurement of circulating microRNA concentrations may report on dynamic changes in platelet biology following a cardiovascular ischemic event.
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Affiliation(s)
| | | | | | | | | | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | | | - Paul A Gurbel
- Inova Heart & Vascular Institute, Falls Church, VA, USA
| | | | | | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Svati H Shah
- Duke Molecular Physiology Institute, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Mark Y Chan
- National University of Singapore, Singapore, Singapore.
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49
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Åkerblom A, Wojdyla D, Steg PG, Wallentin L, James SK, Budaj A, Katus HA, Himmelmann A, Huber K, Siegbahn A, Storey RF, Becker RC. Prevalence and relevance of abnormal glucose metabolism in acute coronary syndromes: insights from the PLATelet inhibition and patient Outcomes (PLATO) trial. J Thromb Thrombolysis 2020; 48:563-569. [PMID: 31512201 PMCID: PMC6800838 DOI: 10.1007/s11239-019-01938-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Diabetes mellitus (DM) and abnormal glucose metabolism are associated with cardiovascular (CV) disease. We investigated the prevalence and prognostic importance of dysglycaemia in patients with acute coronary syndromes (ACS) in the PLATelet inhibition and patient Outcomes (PLATO) trial. Diabetes was defined as known diabetes or HbA1c ≥ 6.5% or non-fasting glucose ≥ 11.1 mmol/L on admission, prediabetes as HbA1c ≥ 5.7% but < 6.5%, and no diabetes as HbA1c < 5.7%. The primary endpoint was the composite of CV death, spontaneous myocardial infarction type 1 (sMI) or stroke at 12 months. Multivariable Cox regression models, adjusting for baseline characteristics, and biomarkers NT-proBNP and troponin I, were used to explore the association between glycaemia and outcome. On admission, 16,007 (86.1%) patients had HbA1c and/or glucose levels available and were subdivided into DM 38.5% (6160) (1501 patients had no previous DM diagnosis), prediabetes 38.8% (6210), and no DM 22.7% (3637). Kaplan Meier event rates at 12 months for CV death, sMI or stroke per subgroups were 14.5% (832), 9.0% (522), and 8.5% (293), respectively with multivariable adjusted HRs, versus no diabetes, for diabetes: 1.71 (1.50–1.95) and for prediabetes 1.03 (0.90–1.19). Corresponding event rates for CV death were 6.9% (391), 3.4% (195) and 3.0% (102), respectively, with adjusted HRs for patients with DM of: 1.92 (1.42–2.60) and for prediabetes 1.02 (0.79–1.32). Abnormal glucose metabolism is common in ACS patients, but only patients with definite DM have an increased CV risk, indicating that prediabetes is not immediately associated with worse CV outcomes.
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Affiliation(s)
- Axel Åkerblom
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden. .,Uppsala Clinical Research Center UCR, Uppsala University, Uppsala, Sweden. .,Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA. .,Uppsala Clinical Research Center, Dag Hammarskjölds väg 38, 751 85, Uppsala, Sweden.
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Philippe Gabriel Steg
- INSERM-Unité 1148, Paris, France.,Assistance Publique-Hôpitaux de Paris, Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Paris, France.,Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France.,NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center UCR, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center UCR, Uppsala University, Uppsala, Sweden
| | - Andrzej Budaj
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
| | - Hugo A Katus
- Medizinishe Klinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Kurt Huber
- Department of Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria.,Medical School, Sigmund Freud University, Vienna, Austria
| | - Agneta Siegbahn
- Uppsala Clinical Research Center UCR, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Richard C Becker
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.,Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, Academic Health Center, Cincinnati, OH, USA
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50
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Thomas MR, James SK, Becker RC, Himmelmann A, Katus HA, Cannon CP, Steg PG, Siegbahn A, Lakic T, Storey RF, Wallentin L. Prognostic impact of baseline inflammatory markers in patients with acute coronary syndromes treated with ticagrelor and clopidogrel. Eur Heart J Acute Cardiovasc Care 2019; 10:2048872619878075. [PMID: 31868508 DOI: 10.1177/2048872619878075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 09/04/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Inflammation plays a major role in the pathophysiology of coronary artery disease. We aimed to determine whether baseline inflammatory markers were associated with clinical outcomes and the observed superiority of ticagrelor compared to clopidogrel in patients with acute coronary syndromes in the PLATO study. METHODS Blood samples were collected from 16,400 patients within 24 hours of the onset of acute coronary syndrome, at the time of random assignment to ticagrelor or clopidogrel in the PLATO study and prior to invasive procedures. The differential white blood cell count and plasma levels of C-reactive protein, interleukin-6 and interleukin-10 were determined and their relationships with clinical outcomes were assessed according to quartiles and using continuous models. The substudy primary endpoint was a composite of cardiovascular death and myocardial infarction. RESULTS Compared to the lowest quartile, the risk of the primary endpoint was significantly elevated in patients in the highest quartile of white blood cell count (hazard ratio (HR) 1.30; P=0.01), neutrophil count (HR 1.33; P=0.007), monocyte count (HR 1.24; P=0.004), C-reactive protein (HR 1.93; P<0.001) and interleukin-6 (HR 2.29; P<0.001). This was predominantly driven by an association with cardiovascular death. Following adjustment for clinical characteristics, troponin, cystatin C and N-terminal pro-brain-type natriuretic peptide, only white blood cell count and neutrophil count maintained a significant association with the primary endpoint. Ticagrelor had a consistent relative cardiovascular benefit compared to clopidogrel in each quartile of each of the inflammatory markers. CONCLUSIONS Acute coronary syndrome patients with elevated levels of baseline inflammatory markers are at increased risk of adverse cardiovascular events, particularly cardiovascular death. The consistent cardiovascular benefit of ticagrelor compared to clopidogrel tended to confer a greater absolute risk reduction in patients with the highest levels of inflammatory markers, as they were at highest risk.
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Affiliation(s)
- Mark R Thomas
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK
- Institute of Cardiovascular Sciences and UHB and SWBH NHS Trusts, University of Birmingham, UK
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Sweden
- Uppsala Clinical Research Center, Uppsala University, Sweden
| | | | | | - Hugo A Katus
- Medizinishe Klinik, Universitätsklinikum Heidelberg, Germany
| | | | - Philippe Gabriel Steg
- INSERMU1148, Paris, France
- Département Hospitalo-Universitaire FIRE, Hôpital Bichat, France
- Université Paris-Diderot, Sorbonne-Paris Cité, France
- NHLI Imperial College, Royal Brompton Hospital, UK
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Sweden
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden
| | - Tatevik Lakic
- Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Sweden
- Uppsala Clinical Research Center, Uppsala University, Sweden
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